Tobias Reichlin1, Raphael Twerenbold1, Karin Wildi1, Maria Rubini Gimenez1, Nathalie Bergsma1, Philip Haaf1, Sophie Druey1, Christian Puelacher1, Berit Moehring1, Michael Freese1, Claudia Stelzig1, Lian Krivoshei1, Petra Hillinger1, Cedric Jäger1, Thomas Herrmann1, Philip Kreutzinger1, Milos Radosavac1, Zoraida Moreno Weidmann1, Kateryna Pershyna1, Ursina Honegger1, Max Wagener1, Thierry Vuillomenet1, Isabel Campodarve1, Roland Bingisser1, Òscar Miró1, Katharina Rentsch1, Stefano Bassetti1, Stefan Osswald1, Christian Mueller2. 1. Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland. 2. Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland chmueller@uhbs.ch.
Abstract
BACKGROUND: We aimed to prospectively validate a novel 1-hour algorithm using high-sensitivity cardiac troponin T measurement for early rule-out and rule-in of acute myocardial infarction (MI). METHODS: In a multicentre study, we enrolled 1320 patients presenting to the emergency department with suspected acute MI. The high-sensitivity cardiac troponin T 1-hour algorithm, incorporating baseline values as well as absolute changes within the first hour, was validated against the final diagnosis. The final diagnosis was then adjudicated by 2 independent cardiologists using all available information, including coronary angiography, echocardiography, follow-up data and serial measurements of high-sensitivity cardiac troponin T levels. RESULTS: Acute MI was the final diagnosis in 17.3% of patients. With application of the high-sensitivity cardiac troponin T 1-hour algorithm, 786 (59.5%) patients were classified as "rule-out," 216 (16.4%) were classified as "rule-in" and 318 (24.1%) were classified to the "observational zone." The sensitivity and the negative predictive value for acute MI in the rule-out zone were 99.6% (95% confidence interval [CI] 97.6%-99.9%) and 99.9% (95% CI 99.3%-100%), respectively. The specificity and the positive predictive value for acute MI in the rule-in zone were 95.7% (95% CI 94.3%-96.8%) and 78.2% (95% CI 72.1%-83.6%), respectively. The 1-hour algorithm provided higher negative and positive predictive values than the standard interpretation of highsensitivity cardiac troponin T using a single cut-off level (both p < 0.05). Cumulative 30-day mortality was 0.0%, 1.6% and 1.9% in patients classified in the rule-out, observational and rule-in groups, respectively (p = 0.001). INTERPRETATION: This rapid strategy incorporating high-sensitivity cardiac troponin T baseline values and absolute changes within the first hour substantially accelerated the management of suspected acute MI by allowing safe rule-out as well as accurate rule-in of acute MI in 3 out of 4 patients. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00470587.
BACKGROUND: We aimed to prospectively validate a novel 1-hour algorithm using high-sensitivity cardiac troponin T measurement for early rule-out and rule-in of acute myocardial infarction (MI). METHODS: In a multicentre study, we enrolled 1320 patients presenting to the emergency department with suspected acute MI. The high-sensitivity cardiac troponin T 1-hour algorithm, incorporating baseline values as well as absolute changes within the first hour, was validated against the final diagnosis. The final diagnosis was then adjudicated by 2 independent cardiologists using all available information, including coronary angiography, echocardiography, follow-up data and serial measurements of high-sensitivity cardiac troponin T levels. RESULTS: Acute MI was the final diagnosis in 17.3% of patients. With application of the high-sensitivity cardiac troponin T 1-hour algorithm, 786 (59.5%) patients were classified as "rule-out," 216 (16.4%) were classified as "rule-in" and 318 (24.1%) were classified to the "observational zone." The sensitivity and the negative predictive value for acute MI in the rule-out zone were 99.6% (95% confidence interval [CI] 97.6%-99.9%) and 99.9% (95% CI 99.3%-100%), respectively. The specificity and the positive predictive value for acute MI in the rule-in zone were 95.7% (95% CI 94.3%-96.8%) and 78.2% (95% CI 72.1%-83.6%), respectively. The 1-hour algorithm provided higher negative and positive predictive values than the standard interpretation of highsensitivity cardiac troponin T using a single cut-off level (both p < 0.05). Cumulative 30-day mortality was 0.0%, 1.6% and 1.9% in patients classified in the rule-out, observational and rule-in groups, respectively (p = 0.001). INTERPRETATION: This rapid strategy incorporating high-sensitivity cardiac troponin T baseline values and absolute changes within the first hour substantially accelerated the management of suspected acute MI by allowing safe rule-out as well as accurate rule-in of acute MI in 3 out of 4 patients. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00470587.
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